aetiology, Causes of cheilitis, Chapping due to cold and wind , Eczematous cheilitis, Contact cheilitis, Drug-induced cheilitis, Infective cheilitis

1. Tutorial presentation
Cheilitis
Presenter:- Dr. Pradeep Garg

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Synonym- Inflammation of the lips
May arise as a
Primary disorder of the vermilion zone or
Inflammation may extend from nearby skin or,
Less often, from the oral mucosa

3. Causes of cheilitis.
Chapping due to cold and wind
Actinic prurigo of the lip
Eczematous cheilitis
Glandular cheilitis
Contact cheilitis
Granulomatous cheilitis
Drug-induced cheilitis
Exfoliative (factitious) cheilitis
Infective cheilitis
Plasma cell cheilitis
Angular cheilitis
Nutritional cheilitis
Ultraviolet irradiation
Dermatoses
Actinic cheilitis
Trauma

4. ‘Chapping’ of the lips
• Reaction to adverse environmental
conditions
• Caused by exposure to freezing cold or to
hot dry winds.
• Keratin of the vermilion loses its
plasticity, so that the lips become sore,
cracked and scaly.
• Affected person tends to lick the lips, or
to pick at the scales, which may
aggravate the condition.
• Treatment- Petroleum jelly and avoidance
of the adverse environmental conditions

5. Eczematous cheilitis
• Presenting as redness with
dryness, scaling and fissuring.
• Major causes- atopic
dermatitis and irritant or
allergic contact reactions
• Treatment- Emollients and
topical corticosteroids.
• A potent steroid may be
required to bring the
condition under control

6. Contact cheilitis
• F>M
• Affect all age groups, but adults>children.
• Lip cosmetics are the most common allergen source in
women, and toothpastes in men.
• Medications in the elderly.
• Dental materials and oral hygiene products in all age
groups.
• Reactions to food mainly affect children.
• Patients are often also atopic.

7. • Major sources of allergens :
• Lipsticks and other lip cosmetics including sunscreens
• Toothpaste and other dental care products (mouthwash,
denture cleaner, dental floss, toothpicks)
• Metals – dental restorations, orthodontic devices, musical
instruments, metal casings of lip cosmetics, habitual
sucking of metal objects
• Food, Medications, Nail varnishes
• Rubber/latex gloves
• Common allergen groups:
• Metals such as nickel
• Fragrance/Flavourings and Preservatives

8. • C/f- Lipstick cheilitis may confined to the vermilion or
extends beyond.
• Persistent irritation and scaling or a more acute reaction
with oedema and vesiculation.
• Other forms of cheilitis vary greatly in their clinical
appearance.
• Foods commonly also involve the skin around the mouth.
• If a small, sucked object is responsible, the reaction may be
confined to one part of the lips

9. • Diagnosis- If acute eczematous changes- contact cheilitis .
• If the changes are confined to irritation and scalingexfoliative cheilitis must be excluded.
• If an allergic reaction is suspected, patch tests should be
carried out.
• Treatment- Topical corticosteroids will give symptomatic
relief but the offending substance must be identified and
avoided

10. Infective cheilitis
• Viral- HSV are common, and VZV and HPV may also affect
the lips.
• Bacterial- Dental infection or occasionally a furuncle or
carbuncle may cause swelling of the lip.
• Impetigo may mimic herpes labialis.
• Lip is the MC extragenital site for a primary syphilitic lesion.
• Most lip chancres in males tend to occur on the upper lip,
in females on the lower lip.

11. • In secondary syphilis, moist, flat, papulonodular lesions
(condylomata lata) often appear at the mucocutaneous
junctions and commissures.
• TB or leprosy may cause chronic lip swelling or ulceration
• Rhinoscleroma initially affects the nasal mucosa but may
spread slowly to the upper lip, producing plaques or
nodules with sunken centres.
• Extreme hardness of the infiltrations is characteristic.

12. • Protozoal- Cutaneous or mucocutaneous leishmaniasis
typically causes swellings on the upper lip with later
enlargement and destruction of the lip, reflecting the three
stages of oedema, granulomatous proliferation and then
necrosis.
• Fungal- Blastomycosis and paracoccidioidomycosis are
uncommon causes of chronic ulceration affecting the lip,
producing very similar clinical lesions to leishmaniasis.
• Others- Red swollen lips with fissuring and exfoliation are
prominent in mucocutaneous lymph node syndrome
(Kawasaki disease).

13. Angular cheilitis
Synonym-Angular stomatitis
• Acute or chronic inflammation of the skin and contiguous
labial mucous membrane at the angles of the mouth.
• Aetiology• Dribble of saliva causing eczematous cheiltiis, a form
of contact irritant dermatitis
• Overhang of upper lip resulting in deep furrows
(marionette lines)
• Dry chapped lips
• Proliferation of bacteria (impetigo), yeasts (thrush) or virus
(cold sores)

14. • Affects children and adults, in poor health.
• Predisposing factors include:
• Oral thrush: infancy, old age, diabetes, systemic
corticosteroid or antibiotic use
• Dentures, especially if they are poor fitting, and there is
associated gum recession
• Poor nutrition: coeliac disease, iron deficiency, riboflavin
deficiency
• Systemic illness, particularly IBD (ulcerative colitis
and Crohn disease)
• Sensitive skin, especially atopic dermatitis
• Genetic predisposition, for example in Down syndrome
• Oral retinoid

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C/fPainful cracks / fissures
Blisters / erosions / ooze / crusting
Redness, Bleeding
It may progress to more widespread impetigo or candidal
skin infection on the adjacent skin and elsewhere.
Investigations
Culture of swabs taken from the corners of the mouth may
reveal:
Candida albicans
Staphylococcus aureus
Herpes simplex

16. Angular cheilitis

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TreatmentLip balm or thick emollient ointment, applied frequently
Topical antiseptics
Topical or oral antibiotic
Topical antifungal cream
Oral antifungal medication
Topical steroid ointment
Nutritional supplements
Filler injections or implants to build up the oral
commissures

18. Actinic cheilitis
• Synonyms-Actinic keratosis of lip • Solar cheilosis
• Aetiology- MC in hot dry regions, in outdoor workers and in
fair-skinned people (skin types I and II).
• Vermilion of the lower lip receives a high dose of UV
irradiation because it is almost at right angles to the rays of
the midday sun and is poorly protected by keratin and
melanocytes.

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C/f- Dry lips, Thinned skin of the lips, Scaly patches
Less common features:
Swelling of the lip
Redness and soreness, Ulceration and crusting
Loss of demarcation between the vermilion border of the
lip and its adjacent skin
• Prominent folds and lip lines
• White thickened patches (leukokeratosis)
• Discoloured skin with pale or yellow areas

20. Chronic actinic cheilitis with leukoplakia
actinic cheilitis

21. • Treatment- to relieve symptoms and to prevent
development of SCC
• Topical agents: 5% fluorouracil TDS for 10 days is suitable.
• Tretinoin, TCA or diclofenac gel may also be effective.
• Vermilionectomy (lip shave).
• Laser ablation.
• Photodynamic therapy.
• Following treatment, prevention of recurrence by the
regular use of a sunscreen lipsalve containing paminobenzoic acid probably gives the best protection.

22. Glandular cheilitis
• Inflammatory changes and swelling of salivary glands in the
lips.
• Aetiology- idiopathic, few cases familial.
• Excessive salivary secretion from minor salivary glands, an
unusual clinical response to irritation of the lip from some
other cause such as actinic damage or repeated licking.
• C/f- Lower lip is slightly thickened and bears numerous
pinhead-sized orifices, from which mucous saliva can readily
be squeezed.
• Upper lip is rarely involved
• In the more severe suppurative form (Volkmann’s cheilitis) the
lip is considerably and permanently enlarged, and subject to
episodes of pain, tenderness and increased enlargement.

23. • Surface is covered by crusts and
scales, beneath which the
salivary duct orifices may be
discovered.
• In the most severe forms there
may be deep-seated infection
with abscess formation and
fistulous tracts.
• In some series 20–30% of cases
progress to SCC.
• In many cases it is a
consequence of actinic cheilitis.
• T/t- If the lips are grossly
enlarged, excision of an
elongated ellipse of tissue may
be required

24. Granulomatous cheilitis
• Lumpy swelling of the lips.
• Different causes, such as allergy, Crohn disease, sarcoidosis
and orofacial granulomatosis.
• Rare causes are infections, cancers and genetic disorders.
• Miescher-Melkersson-Rosenthal syndrome refers to
recurrent chronic swelling and enlargement of one or both
lips.
• Facial palsy and fissuring of the tongue may also occur.
• Cause- not known, but genetics may have a role.
• In Miescher cheilitis, the changes are confined to the lip.
• First symptom is a sudden swelling of the upper lip.

25. • Swelling of the lower lip and one or both cheeks may follow in
Melkersson-Rosenthal syndrome.
• Less commonly, the forehead, eyelids, or one side of the scalp
may be involved.
• Swelling may feel soft, firm or nodular when touched.
• Recurrent attacks may occur within days or even years after
the first episode.
• At each episode the swelling may become larger, more
persistent and eventually become permanent.
• At this time the lips may crack, bleed and heal leaving a
reddish-brown colour with scaling. This can be painful.
• Eventually the lip takes on the consistency of hard rubber.

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Other symptoms include:
Fever, headache and visual disturbances
Mild enlargement of regional lymph nodes in 50% of cases.
Fissured or plicated tongue in 20-40% of cases.
Facial palsy; intermittent, then possibly permanent and can
be unilateral or bilateral, and partial or complete.
• It occurs in about 30% of cases.
• Skin biopsy of the affected tissue shows characteristic
granulomas i.e. a mixed inflammatory cell infiltration in the
dermis.

27. Granulomatous cheilitis of the lower lip.

28. • Treatment- Reactions to dietary components should be
sought and possible antigens avoided.
• Topical corticosteroids
• Long term anti-inflammatory antibiotics e.g. a six to twelve
month course of tetracycline, erythromycin or penicillin
• Corticosteroids injected into the lips to reduce swelling.
Injections need to be repeated every few months.
• NSAIDS
• Mast cell stabilisers eg ketotifen
• Clofazimine
• Sulfasalazine
• Surgical reduction

29. Exfoliative cheilitis
• Presenting as continuous peeling of the lips.
• Factitial- if the behaviour triggering the condition is
attention-seeking.
• Exfoliative - obsessive-compulsive with no intent of gain.
• Mainly affects young adults <30 years with personality
disorders.
• Initiating factors include: Mouth breathing, Lip licking, Lip
sucking, Lip picking, Lip biting.
• Poor oral hygiene, HIV infection and Candida.

30. • C/f- Continuous peeling of the vermilion of the lips.
• Usually affect the lower lip.
• Peeling appears to be cyclical and proceeds at different
rates in different sites, so there is always some part of the
lip peeling at any time.
• There may be associated bleeding resulting in formation of
a haemorrhagic crust.
• Condition may be painful, causing difficulty in eating and
speaking.
• Other symptoms include sensations of: Tingling, Itch,
Dryness, Ulceration or fissuring may occur

31. Factitious cheilitis due to repeated lip sucking

32. Exfoliative cheilitis

33. • Diagnosis- it is a diagnosis of exclusion and there is no
specific diagnostic test for it.
• A careful psychiatric assessment can be especially helpful
• Treatment- Some cases resolve spontaneously or with
improved oral hygiene.
• Reassurance and topical corticosteroids, or tacrolimus may
be helpful in some cases but others require psychotherapy,
antidepressants or tranquillizers.

34. Plasma cell cheilitis
• Uncommon chronic
inflammatory dermatitis that
presents with flat to slightly
elevated erosive erythematous
plaques.
• Genital areas are often
involved, k/a plasma cell
balanitis or vulvitis.
• Sometimes resistant to
conventional topical
corticosteroid therapy
• Recent reports show that
topical calcineurin inhibitors
are effective

35. Lupus erythematosus
• Involvement of the vermilion
zone is quite common in both DLE
and SLE.
• DLE can be premalignant, and
should be treated vigorously with
topical steroid ointments and
sunscreens.
• Cheilitis of SLE more severe, with
erosions and haemorrhagic
crusts.
• Lupus erythematosus can be very
difficult to distinguish from LP of
the lips, both clinically and by
histology

36. THANK YOU

37. • Possible fruit and vegetable allergens.
Apple
Fennel
Asparagus
Artichoke
Carrot
Cherry
Orange
Peach
Pear
Lime
Parsley
Onion
Garlic
Parsnip
Mango
Celery
Potato
Tomato
Pineapple
Plum
Banana

38. Miscellaneous objects-
Metal hair clips
metal pencils
cobalt paint on blue pencils
nail varnish
Wooden
nickel and reed mouthpieces
of musical instruments

39. Lipsticks and lipsalves
mineral oils and wax
oleyl alcohol
castor oil
azulene
lanolin
sesame oil
preservatives,
stearates
perfumes
colophony
colours
eosin
azo dyes
Sunscreens (e.g. cinnamic aldehyde)

40. Mouthwashes and dentrifices, Dental preparations-
essential oils
imonene
peppermint
pinene
cinnamon
phellandrene
spearmint
linalool
carvone
alcohol

41. • It is present from birth in some, which may indicate genetic
susceptibility.
• There may be loss of sense of taste and decreased salivary
gland secretion.
• Regional lymph nodes are enlarged in 50% of cases but not
usually very greatly.
• Facial palsy of the lower motor neurone type occurs in
some 30% of cases.
• It may precede the attacks of oedema by months or years,
but more commonly develops later Although intermittent
at first, the palsy may become permanent.

42. • It may be unilateral or bilateral, and partial or complete.
• Other cranial nerves (olfactory, auditory, glossopharyngeal
and hypoglossal) may occasionally be involved.
• Involvement of the CNS has also been reported, but the
significance of the resulting symptoms is easily overlooked
as they are very variable, sometimes simulating
disseminated sclerosis but often with a poorly defined
association of psychotic and neurological features.
• Autonomic disturbances may occur.

43. • Diagnosis- Essential feature of the syndrome is the
granulomatous swelling of lip or face.
• In the early attacks clinical differentiation from angiooedema may be impossible in the absence of either scrotal
tongue or facial palsy.
• Persistence of the swelling between attacks should suggest
the diagnosis, which can sometimes be confirmed by
biopsy.
• In established cases, other causes of macrocheilia must be
excluded.
• Lymphoma is a rare differential diagnosis.

44. Actinic prurigo
• Familial photodermatitis, Seen in High altitude especially in
Latin America, and in China.
• Young women presents as a photosensitive facial rash with
pruritic lower lip cheilitis,
• May be a/w conjunctivitis, eyebrow alopecia and pterygion.
• Distinguished from actinic cheilitis, which is due to
prolonged and excessive exposure to UV irradiation.
• PMLE is almost invariably present in the actinic prurigo of
native Americans.
• Treatment- Sunscreens, β-carotene, PUVA, and
antihistamines.
• Oral thalidomide may be tried